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Medicare: New Directions in Quality Assurance 21 A Physician's Response to the Institute of Medicine Report Arnold S. Relman I am very pleased to have the opportunity to participate in this meeting and to give you my reactions to this report (IOM, 1990). First, let me make it clear that I speak purely as an individual. The New England Journal of Medicine and its owners, the Massachusetts Medical Society, take no public position on policy issues through the Journal, and I do not express the views of any organization. I express my own personal views for what they are worth. Second, I want to say that I have read the Institute of Medicine (IOM) report and I must say I was impressed. I have been around this institution for a while. I have chaired other studies. I have been involved in the production of reports. I have been on the Executive Council of this organization, so I know something about how it works, and I must say this is a superb job. I congratulate all involved, the committee and the staff. It is a superb job, well thought out, well written, reflecting an enormous amount of hard work and an enormous amount of available information. It is scholarly, comprehensive, and thoughtful. I learned a lot from reading all the facts. It puts everything together. If you want to know what is known and what is not known about quality assurance in this country, there it is. So it is an enormously valuable contribution, and I agree basically with the conceptual analysis. CONCERNS ABOUT THE PROPOSED STRATEGY My concerns about your proposals are similar to your concerns about the continuous improvement model: How might it play out? The ideas are very sound. It is hard to argue against the very sensible and reasonable approach
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Medicare: New Directions in Quality Assurance you take. However, as I try to think about how it would play out and what impact it would have on the practice of medicine, I have some reservations. It all comes down to changing the behavior of physicians. From what I know about the way physicians work and what motivates them. I am concerned that we may be trying to overstructure and overorganize the doctor-patient relationship. The interaction among provider institutions, medical professionals and patients must have a certain degree of autonomy and independence for things to work properly. ECONOMIC ASPECTS OF QUALITY CONCERNS Having said that, let me be a little more specific. I do not think that this report gives sufficient emphasis to the obvious historical fact that concern about quality, the whole quality agenda, comes basically from concern about cost. Yes, it is true that there has always been a concern about the incompetent or the impaired practitioner but basically the reason that the Congress asked the IOM to do this study was not so much worry about bad doctors or bad decisions, but about expensive doctors and expensive decisions. So this is first of all an economic issue. We ought to be paying more attention to economic solutions. The two big problems are, first, the cost of our health care system, and second, the fact that we do not adequately identify, monitor, or prevent poor quality medical care. The first problem of expense is mainly a problem of overuse. We have much more data—good hard information—about overuse being a big problem. I agree with Steven Schroeder (Schroeder, 1991) and his colleagues that underuse is also a problem, but we do not have any data on this. We have the uncomfortable feeling that underuse may be a problem because of the way prepaid health care is structured and the incentives that are involved in prepaid health care, but I do not think that this will turn out to be a major issue except when it comes to limited access. Underuse, as I see it, is mainly an access problem. It is true that we have the extraordinary example of Cody Howard, a child who had leukemia. His was the famous case in Oregon where the third party payer—Medicaid—decided not to provide a useful but high technology medical service, bone marrow transplantation. That is a dramatic headline-catching example of what may well be going on at a much lower technology level in prepaid health care arrangements. Nevertheless, I do not think that this dramatic example is as much a concern as the problem of people who have no insurance coverage who never get into the system at all. For them, the third party payer has no decision to make at all, because those people have no third party coverage. So basically, overuse and underuse are economic problems. How do we deal with that? First, and foremost, we need more information about outcomes
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Medicare: New Directions in Quality Assurance and better evaluation of new technology. Second, we must have more information about what works and what does not, what is cost-effective and what is not. Finally, we have to have more information about what people want, and how they value certain outcomes. I am not going to steal John Wennberg's thunder, because that is the sermon he has been preaching for a long time (Wennberg, 1991), and I totally endorse it. As we look at what works and what does not, what is cost-effective and what is not, and what people want or do not want, it will become clear that much of what we do is not necessary, puts patients at risk, and wastes money. The problem is to organize and fund that kind of research and to make it available to influence doctor behavior. To do that you have to think about the future of medical practice. I do not believe one can very effectively feed back information about outcomes and technology assessment, or assure quality very effectively, through office practice settings. That is true now, and it is going to be true in the future. It is difficult to envision how a really effective quality assurance program could be applied to the office practice of medicine without being terribly expensive and terribly intrusive. I do not see a solution to that problem. Therefore, we have to imagine that an effective quality assurance program will be based largely on physicians practicing in groups. That is my major suggestion for an economic approach to the overuse problem. If we have doctors practicing in groups, then information can be generated about what is done. Better records can be kept. Standards can be applied. Feedback can be much more effective, and professional peer oversight is facilitated. PROFESSIONALISM In groups, furthermore, professional values will have a better opportunity to work. Doctors who are practicing alone are thrown back on their own consciences and their own personal values, their own economic imperatives, and their own psychological needs. Very good doctors, practicing alone, may practice superb medicine, but the average doctor and the less-than-average doctor, practicing alone, are not likely to practice as well as if they were practicing in company with at least a few colleagues, where they can talk to one another, look at one another, report on what they do, and where professional standards and values occur. Professionalism flourishes best when doctors work collegially. Steven Schroeder and I have lived all of our professional lives in a group setting. Of course, each doctor takes care of his or her own patients in an office, and there is a certain private element in the doctor-patient relationship that you cannot do without. I am not saying that patients should be taken care of by a committee of doctors. Medical care should involve one patient and one
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Medicare: New Directions in Quality Assurance doctor at a time. Yet good medical care also requires doctors to be close to their colleagues, to be able to call colleagues in for consultation, to have colleagues look at what they do, to report to their colleagues on what they are doing, and to have collegial judgment and professional standards influence the private interaction between doctor and patient. That is why I believe that one key to improving the quality of health care in the future is to encourage group practice. At the present time I think that less than 5 percent of Medicare is provided through prepayment and group arrangements. We should try to increase that percentage, and we should try to be developing quality assurance methods that focus on doctors practicing in groups. That is where quality assurance is going to be effective, whereas doctors practicing privately and individually in their own offices are going to be very difficult to deal with. Fee-for-service reimbursement along with the technology explosion is a major factor in increasing costs and overuse of services. We have to face that fact. I am not suggesting we outlaw or restrict fee for service. It is not possible legally, and I am opposed to it in principle. The fee for service option is going to be with us for the foreseeable future, but subsidized insurance (Medicare, Medicaid, and all employer-subsidized health insurance) should move toward capitated arrangements and prepayment arrangements with a group practice. Fee for service should be an option available to those who want and can afford it. I liked the emphasis in this report on professionalism rather than regulation, and that is discussed in other papers (Bristow, 1991; Cooney, 1991). The way to implement any quality assurance program is to involve physicians and to hold them collectively responsible for what they do. However, the intrusion, the regulation, the administrative forms, and the paperwork should be minimal. Doctors are fed up with the increasingly intrusive regulation they experience. You cannot manage doctors beyond a certain point without jeopardizing morale, esprit, and professional commitment. When you have a sullen, resentful, demoralized medical profession, you have got bad care. At some point, then, regulation and excessive external concern for quality care become counterproductive because doctors become resistant and angry. I do not want to be taken care of by an angry, sullen, demoralized doctor, nor does anyone. LEGAL ISSUES One big problem the IOM report did not touch on sufficiently is the legal impediments to quality assurance. Two branches of government are telling the medical profession very different things. One branch of government, the executive is saying, "We want you to be concerned about quality; we want you to be more professional; we want you to be more concerned about
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Medicare: New Directions in Quality Assurance improving the doctor-patient relationship; and we want you to act like doctors should." The other branch of government, the judiciary, is saying, "You doctors are fundamentally businessmen. We are going to apply antitrust law to you, just like businessmen. You had better not collude; you had better not get together and worry about standards; you had better not tell your competitors how to conduct their business." These mixed messages—and the legal ramifications of misinterpreting or ignoring them—are a big problem indeed. Medical organizations are afraid of antitrust actions whenever they contemplate disciplinary actions against individual doctors. The fact is that most doctors I know are reluctant to participate in peer review and quality assurance activities because of the legal implications. I know that new legislation is supposed to be protecting them, but the perception and the feelings are that "antitrust law will get you if you do not watch out." COST OF THE NEW PROGRAM I am also concerned about the cost of the program proposed by the IOM committee. Steven Schroeder mentions that it would cost more money (he does not know how much), but it would be worth it (Schroeder, 1991). It will cost a lot of money and require a very large administrative machinery, but my feeling is that we ought to start small. The ideas in this report are excellent, but I would be afraid to start out by applying them wholesale, setting up this new organization, this Medicare Program to Assure Quality (MPAQ). (By the way, the only major criticisms I have of this report are these ghastly new acronyms.) I am concerned about the cost and size of the administrative machinery that would have to be set up, and I am concerned about how you would get all this administrative machinery to work without ruining the morale of the medical profession and ending up with a dispirited, sullen, resentful doctor who says, "I have had it. I am being regulated too much. I went into medicine because I like to take care of patients, and now everyone is telling me what to do." What you have to do is set up mechanisms that rely on doctors to regulate themselves as much as possible. The only way that you can make sure they do this is to have them practice in groups so they can be responsible as groups, manage their own quality assurance, and be accountable for that. In any case, we ought to try out some of the IOM's ideas on a small scale, in demonstration projects and small trials, rather than in a new national program all at once. At the same time, we have to deal with the problem of incompetence, which clearly exists. We are going to hear from the Harvard School of Public Health Liability Study that approximately 3 or 4 percent of all hospital admissions lead to one or more adverse events, and about 20 or 25 percent
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Medicare: New Directions in Quality Assurance of those adverse events, or about 1 percent of all hospital admissions, are associated with negligence. Now that is a big problem. The way to deal with that problem is through a no-fault compensation approach coupled that with a very rigorous and fair system of professional review. We are going to have to set up panels and machinery linked to the occurrence of adverse events for identifying poor practitioners and impaired physicians, and for dealing with them in some way. SUMMARY The quality problem is largely a matter of overuse, limited access, underuse, and incompetence. Limited access and underuse, as they relate to insurance coverage, were clearly not the responsibility of the IOM study committee. We all know that we have got to have a system that provides adequate insurance for all Americans, but that is a separate problem. The overuse problem can be dealt with through an outcomes and effectiveness approach, like that pioneered by John Wennberg, linked to a gradual movement away from solo practice and fee for service to group practice and capitation. We should make groups responsible for managing the care that they provide, based on the information that will come from a greatly expanded national program of technology assessment outcomes and effectiveness research. We need to put a lot of money into these efforts, and it will be an excellent investment. Although there is no time to discuss this here, a reform in the fee scale would also be helpful in reducing overuse of specialized services. The problem of incompetence is not being effectively dealt with by the tort liability system. The Harvard study confirms an earlier study in California and doctors, of course, do not need convincing. Doctors have believed for a long time that the tort system was just not working, and the new evidence supports that view. It is not serving patients; it is not serving the profession; it is not serving the public; it is serving the trial lawyers. We should replace it with a no-fault system of some kind and couple that to a very carefully thought-out system for identifying adverse events, negligent practitioners, and impaired practitioners and dealing with them in a way that the public can accept. In short, I like your report. I think it is conceptually correct. My concern is how your recommendations would play out. The risk is that we would be overadministered and overorganized, and doctors would feel even more harrassed than now. Therefore, I would like to see you start more modestly with demonstration products while working toward making doctors take more responsibility for managing their own care.
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Medicare: New Directions in Quality Assurance REFERENCES Bristow, L.R. More Professionalism, Less Regulation: A Response. Pp. 22-26 in Medicare: New Directions in Quality Assurance. Donaldson, M.S., Harris-Wehling, J., and Lohr, K.N., eds. Washington, D.C.: National Academy Press, 1991. Cooney, L.M. More Professionalism, Less Regulation: The Committee View. Pp. 18-21 in Medicare: New Directions in Quality Assurance. Donaldson, M.S., Harris-Wehling, J., and Lohr, K.N., eds. Washington, D.C.: National Academy Press, 1991. Institute of Medicine. Medicare: A Strategy for Quality Assurance. Volumes I and II. Lohr, K.N., ed. Washington, D.C.: National Academy Press, 1990. Schroeder, S.A. The Institute of Medicine Report. Pp. 7-14 in Medicare: New Directions in Quality Assurance. Donaldson, M.S., Harris-Wehling, J. and Lohr, K.N., eds. Washington, D.C.: National Academy Press, 1991. Wennberg, J.E. A Patient Outcomes Orientation: A Response. Pp. 73-78 in Medicare: New Directions in Quality Assurance. Donaldson, M.S., Harris-Wehling, J., and Lohr, K.N., eds. Washington, D.C.: National Academy Press, 1991.
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